Sometimes the problem is that you just can't breath well through your nose. This is especially likely to bother people at night. It is often not entirely clear what the cause is. The most common diagnoses would be a nasal septal deviation, turbinate hypertrophy, and chronic sinusitis.

One problem is that the decongestant sprays are not at all good if used routinely and oral decongestant pills have side effects and interfere with sleep.

I have included steroid nasal sprays in the OTC category because they should be OTC, but in the U.S. they are currently only by prescription. You should try to obtain one of the preferred brands, and use 2 squirts in each side of your nose before bed every night. They are OTC in other countries and are available on line (sorry no specifics available). Sometimes it is all that is needed to tip the scale in your favor. Give this type of medicine about a week before drawing any conclusion about its effectiveness.

It is common for people to confuse antihistamines and decongestants. Antihistamines specifically block a part of the allergic pathway, decongestants nonspecifically open nasal passages regardless of the cause by shrinking blood vessels.



"First Generation Antihistamines"

These are the original older antihistamines. They work very well but for many people they have the side effects of sedation and dry mouth. They include original Benadryl (diphenhydramine), Tavist Allerfy (clemastine), and Chlortrimeton (chlorpheniramine). Tavist is the only one with an intrinsic 12 hour duration. Tavist Allergy (plain clemastine fumarate), not Tavist - D is probably the best choice in this category.


"Second Generation" Antihistamines

We now have the ingredient in Claritin available OTC, loratidine. This antihistamine often works well, and has the benefits of being once a day and having no side effects. It has the negatives of being a bit more expensive, and quite a bit less effective in relieving symptoms. Get the generic and give it a try, if it helps, it can be a really good medicine with no side effects or drug interactions. The more effective second generation antihistamines are still prescription, but that may soon change. Allegra, Zyrtec, and Clarinex are the notable examples. Allegra has just become generic and may convert to OTC soon.

My recommendation for an OTC Antihistamine

To keep it simple, the over the counter antihistamine to try first is Tavist Allergy. The ingredient is clemastine fumarate. This medicine is more effective than newer, more expensive prescription antihistamines, but in some people it causes drowsiness. The benefit is that it works better and is much less expensive. The side effects often become less evident over time.

If you find that clemastine fumarate causes too many side effects, you should try loratidine next. This is the ingredient in OTC Claritin, Alavert, and the generic store brands. It is basically free of any side effects and for some people it is quite effective. The negative is that it is more expensive and it is less effective.
If this problem is every night and day, then you need to see a specialist. Your problem may be chronic sinusitis, and may benefit from prescription medicines and diagnostic studies. There are times when minor procedures done in the office can relieve the problem. Other times minor outpatient surgical procedures are needed. Trouble breathing through the nose is the symptom that is most reliably correctable if surgery is needed. You can live with it, but you don't have to. 

Decongestant nasal sprays are difficult for doctors to recommend. If used correctly, they are the best medicine that we have as a short term decongestant, but if used for just a little bit too long, they cause problems. They are generally safe even if overused. People who use them daily for long periods of time will have problems until they completely discontinue the sprays.


There are 2 common ingredients of sprays: phenylephrine (Neo-Synephrine), and oxymetazoline (Original Afrin or Neo-Synephrine 12 hour). Oxymetazoline nasal sprays are the best of the decongestant sprays because they are the most available and do not increase blood pressure or heart rate as much phenylephrine. They last 12 hours, and are generally safe.

How much can you safely use?

The common advice is that you can use 2 squirts in each side, every 12 hours for 3 days, then you must stop entirely for a week before starting again. That's 12 full squirts in 10 days. If you have a cold or a brief allergy exposure, then this should be almost long enough. If you have used it for a cold or other possible infection, you should throw the bottle out to prevent spreading the infection to others or giving it back to yourself at a later time.

There are ways to get the benefits for longer. The so called rebound effect occurs locally in the tissues and is related to the dose and to the frequency. This means that if you use it on just one side, the other side doesn't accrue the negative influence for that dose. People get by pretty well with just one side of their nose open. If you wanted, you can spread out the doses by using the medicine on one side one night, and the other side the next night. I suspect you can go a week or a bit longer without problems if you alternate sides with each application.

Also, the rebound effect is less dramatic if you use a lesser concentration. Consider dumping out 1/2 of the bottle and filling with nasal saline spray. By cutting the spray concentration in half, you can extend the amount of time that these sprays can be used. Use one squirt of half strength spray, this will still open most people up quite well, and it is only 1/4 of the full dose.

So how does this medicine make you addicted?

Addicted isn't really the best word, I think "trapped" better describes it. The phenomenon is called the rebound phenomenon. Let's go over the course of events that represents the most common victim of this trap.

OK, so Jack usually doesn't have chronic nasal problems. One day he wakes up all congested. It's probably a cold or some acute allergic exposure. He buys a bottle of 4-Way® spray at the grocery. A couple of big squirts, and everything is great. He uses it at night and in the mornings. Initially, when this medicine is sprayed, it dramatically shrinks swollen membranes. Once it wears off, initially in 12 hours, the membranes go back to their previous condition. He continues this pattern for days. Now, unknown to Jack, at about day 5, the swelling from his cold has passed for the most part, however, when it is time for bed, his nose is still congested. He uses the spray again, no sense in not breathing well though the night, is there? This pattern continues for weeks.

After the first 4 or 5 days, things have changed. The spray doesn't quite last 12 hours and more importantly, when it wears off, the mucous membranes don't go back to their previous condition, they go to their previous condition plus they swell up some just from wanting more spray. A self fulfilling prophesy has begun. The swelling and congestion is now from recent use of the spray, not from the cold or allergy that started the whole process.

So now if Jack had just muddled through a the little bit of congestion that was present on day 4 and 5, the problem would be gone, but now the a new problem has replaced it. On day 4+, you can convert over to decongestant pills, they don't work as well and have more side effects but they don't cause the rebound effect like the sprays do. Some people fall into this trap and remain in the vicious cycle for years.

I've got a question, why does the bottle clearly say to use it for 3 days only, and why do the bottles have enough for a month at the full rate?

Medicines in this category are helpful to reduce sinus pain. They may also help nasal congestion slightly. During a cold or allergy, you can get negative sensations that do not really rise to the level of pain, such as an itchy scratchy feeling or a burning sensation. These medicines help those sensations too. It is important to be sure that you can take medicines in this class safely, the class is called the Non Steroidal Anti-Inflammatory class, NSAIDs.


The main OTC medicines that can help sinus pain are ibuprofen, aspirin, and tylenol. Ketoprophen (Aleve) is similar to ibuprofen. My preferred ingredient is ibuprofen.

I recommend trying (2) 200 mg ibuprofen every 8 hours. Of course. read the label first. Try it for your nasal symptoms. It is best not to use ibuprofen on an extremely regular basis or for long periods of time. If you need it this often, you probably need to be evaluated by a specialist.

Other Choices

Aspirin is best avoided, it is not more effective then ibuprofen and it can cause more stomach problems then ibuprofen. There is also a rare dangerous problem with aspirin called Reye's syndrome that mostly happens in teens given aspirin during a flu like illness.

Tylenol is very safe when used in the correct amounts, but if overdosed, it is one of the most dangerous medicines. Tylenol has very little anti-inflammatory benefits and just my personal experience suggests that it doesn't help the sinus problems as much as ibuprofen.

Unfortunately, the OTC cough suppressants are not very effective. We have a couple of small, slightly positive studies that show effectiveness with dextromethorphan and codeine, but there is a big recent study that shows no benefit, especially in children. It is probably not worth confusing things by trying to add a cough suppressant, especially since they probably don't work. Don't expect too much from any of them. 

If you have cough that is keeping you awake at night, or comes in long spurts that wear you out, codeine is probably your best bet. You can get codeine containing cough medicine "OTC" by speaking with the pharmacist. Tell them about your cough, and ask for a small amount of Robitussin - AC or a generic form of it. It's the pharmacists decision as to whether to "prescribe" it and he will tell you the dosage.

Dextromethorphan in pill or syrup form seems to help some people. Dextromethorphan has significant side effects, especially in the elderly, of confusion and dizziness. 

There is very little evidence that guaifenesin (the main mucous thinner) is of any value to people with sinus and nasal problems. Routinely adding this type of medicine in is likely to be more confusing than it is worth. Some patients and doctors love this stuff and believe that it is very helpful.

This ingredient is now available OTC as Mucinex® 600 mg tablets. If you want to see if a mucous thinner helps your symptoms, take 2 of these every 12 hours. That is a total of 2400 mg per day. The most common side effect is stomach upset.

The most likely thing to benefit would be a dry non productive cough, or a thick mucous that stick in your throat or chest.

I don't recommend this medicine often, but it is safe and generally well tolerated. The ingredient is included in many combination medicines, the prescription drug makers will adjust the amount of guaifenesin to make it just different enough that it can't be substituted. this is definately a marketing and financial decision, not a medical one.

You have very little to lose by taking this medicine, it is relatively inexpensive and safe. Be careful that it doesn't distract you from taking the more effective medicines.

Many people find that rinsing the nasal cavity with salt water (saline) solutions can provide relief from congestion and other nasal symptoms caused by infections, allergies, dust exposure, or anatomic abnormalities. It's hard to imaging a safer or more economical remedy to try. Basically you mix or buy a salt water solution and some device for squirting a couple of ounces of it up your nose.
What materials are needed?

A do-it-yourself method of mixing saline nasal spray for irrigation is to mix a combination of 1/4 teaspoon of non-iodized salt ( popcorn salt or pickling salt) and 1/8 teaspoon of baking soda (optional) per 1 cup (8 ounces) of clean water. You can use a nasal bulb, available at any pharmacy to instill the solution.

How to do it

Stand in front of a sink and bend forward look down at the drain. Keep your mouth open, take a deep breath and as you blow out of your nose mostly and mouth slightly, squirt as much saline in one side of your nose as you comfortably can. Experiment with side to side head positiions. Do not swallow the salt water and do not block the nasal passage comletely with the bulb tip. If you can stand it, right at the end of the procedure, sniff some of the salt water that is left in your nose back to rinse out deeper portions. Then blow your nose repeatedly. Repeat this on the other side. Use 2 to 4 oz. (60 ml to 120 ml.) on each side

NeilMed has the best commercially available solution mixes and application bottles. I recommend them to my patients. NeilMed has good service and surprisingly low prices.

NeilMed's website.

These medicines seem able to reduce the duration of a common cold. They have been studied in well controlled scientific studies. There are two forms of zinc gluconate preparation that are of interest. The zinc gluconate lozenges, (Cold-Eeze) and zinc gluconate nasal spray (Zicam Cold Remedy).

Zicam "cold remedy" spray was sold until recently.   It was taken off of the market and replaced with a wet nasal swab containing zinc gluconate.  There were reports of people perhaps damaging their sense of smell.  To prevent the medication from getting high in the nasal cavity it was changed from a spray to a wet swab. 

 Two well designed studies show the spray to be dramatically effective in reducing the duration of the common cold. My family and I use it. I have had several 1 or 2 day colds when I have uses it. It not clear if the swabs are as effective..   

I often will use both Zicam spray/swabs and zinc lozenges together.  The spray (no longer available) and the swabs areis irritating and  at first and may make you sneeze. If you use them, it is important to start them as soon as you first notice the signs that suggest you have a cold. 

This category is OTC in some forms and presciption in others.  The most common brand is Flonase and it is available in full strength over-the-counter.  No brand of the steroid sprays has been shown to be superior to any of the others. These sprays are not the type you can become "addicted" to.

Steroid nasal sprays are the single most important medicine for treating nasal allergies.

Steroid sprays are more effective then antihistamines at relieving congestion, often the worst symptom. They are generally free of side effects, and are thought to be safe even for relatively long term use, even in children. The newer generation of sprays are preferred because they are not absorbed into the system to any degree, the older versions are absorbed to some degree creating some potential for long term side effects.

Futicasone (Flonase), triamcinolone (Nasacort AQ),mometasone (Nasonex), budesonide (Rhinocort), and are the versions to look for. They are all equally effective.

If you have nasal allergies, you need to try steroid sprays. I prefer to have patients use them before bed. You should use them for a week straight before making an assessment of their effectiveness. They do not work instantly like decongestant nasal sprays.This category is OTC in other countries, and is fairly easy to obtain by mail order (you're on your own on this one however). It will likely be made available OTC in the U.S. soon. These sprays are not the type you can become "addicted" to.

Steroid nasal sprays are the single most important medicine for treating nasal allergies.

Steroid sprays are more effective then antihistamines at relieving congestion, often the worst symptom. They are generally free of side effects, and are thought to be safe even for relatively long term use, even in children. The newer generation of sprays are preferred because they are not absorbed into the system to any degree, the older versions are absorbed to some degree creating some potential for long term side effects.

Futicasone (Flonase), triamcinolone (Nasacort AQ),mometasone (Nasonex), budesonide (Rhinocort), and are the versions to look for. They are all equally effective.

If you have nasal allergies, you need to try steroid sprays. I prefer to have patients use them before bed. You should use them for a week straight before making an assessment of their effectiveness. They do not work instantly like decongestant nasal sprays.